Attorney General James and U.S. Department of Labor Deliver $14 Million to Consumers Who Were Denied Mental Health Care Coverage

Press Release

NY Attorney General

Posted 12 August 21

New York Attorney General Letitia James and the U.S. Department of Labor (USDOL) today announced landmark agreements with UnitedHealthcare (United), the nation’s largest health insurer, to resolve allegations that United unlawfully denied health care coverage for mental health and substance use disorder treatment for thousands of Americans. As a result of these agreements, United will pay approximately $14.3 million in restitution to consumers affected by the policies, including $9 million to more than 20,000 New Yorkers with behavioral health conditions who received denials or reductions in reimbursement. New York and federal law requires health insurance plans to cover mental health and substance use disorder treatment the same way they cover physical health treatment. The agreements — which resolve investigations and litigation — address United’s policies that illegally limited coverage of outpatient psychotherapy, hindering access to these vital services for hundreds of thousands of New Yorkers for whom United administers behavioral health benefits. In addition to the payment to impacted consumers, United will lift the barriers it imposed and pay more than $2 million in penalties, with $1.3 million going to New York state.  

“In the shadow of the most devastating year for overdose deaths and in the face of growing mental health concerns due to the pandemic, access to this care is more critical than ever before,” said Attorney General James. “United’s denial of these vital services was both unlawful and dangerous — putting millions in harm’s way during the darkest of times. There must be no barrier for New Yorkers seeking health care of any kind, which is why I will always fight to protect and expand it. I thank Secretary Walsh for his partnership on this important matter.” 

“Protecting access to mental health and substance use disorder treatment is a priority for the Department of Labor and something I believe in strongly as a person in long-term recovery,” said U.S. Secretary of Labor Marty Walsh. “This settlement provides compensation for many people who were denied full benefits and equitable treatment. We appreciate Attorney General James and her office for their partnership in investigating, identifying, and remedying these violations.” 

New York’s behavioral health parity law — originally enacted as “Timothy’s Law” in 2006 — and the federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) require insurance coverage for mental health and substance use disorder treatment to be no more restrictive than insurance coverage for physical health conditions. The agreements are the product of the first joint state-federal enforcement of these laws.  

The pressor is here.

Health Insurers Are Still Skimping On Mental Health Coverage

Jenny Gold
Kaiser Health News/NPR
Originally published November 30, 2017

It has been nearly a decade since Congress passed the Mental Health Parity And Addiction Equity Act, with its promise to make mental health and substance abuse treatment just as easy to get as care for any other condition. Yet today, amid an opioid epidemic and a spike in the suicide rate, patients are still struggling to get access to treatment.

That is the conclusion of a national study published Thursday by Milliman, a risk management and health care consulting company. The report was released by a coalition of mental health and addiction advocacy organizations.

Among the findings:

• In 2015, behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care.


• Insurers paid primary care providers 20 percent more for the same types of care than they paid addiction and mental health care specialists, including psychiatrists.


• State statistics vary widely. In New Jersey, 45 percent of office visits for behavioral health care were out-of-network. In Washington, D.C., it was 63 percent.

The researchers at Milliman examined two large national databases containing medical claim records from major insurers for PPOs — preferred provider organizations — covering nearly 42 million Americans in all 50 states and D.C. from 2013 to 2015.

The article is here.

Why are doctors burned out? Our health care system is a complicated mess

By Steven Adelman and Harris A. Berman
STAT News
Originally posted December 15, 2016

Here is an excerpt:

Burnout and dissatisfaction with work-life balance are particularly acute for adult primary care physicians — the central figures in our unsystematic health care “system.” A system that was already teetering in 2011 has been stressed by the addition of 20 million covered lives by the Affordable Care Act. It’s little wonder that in Massachusetts, where near-universal coverage has filled up the offices of primary care physicians, malpractice claims against them are rising. Patients and physicians alike complain about the unsatisfying brevity of office visits, and many harbor intense feelings of antipathy towards cumbersome electronic health records and growing administrative burdens.

We believe that to alleviate the stress and burnout in the medical professions, we must pay attention to system factors that lead to what we call the “occupational health crisis in medicine.” We recently surveyed 425 practicing physicians and health care leaders and executives, seeking their opinions on the importance of eight approaches to transforming health care. We presented the results this fall at the International Conference on Physician Health.

The article is here.

The Problem With Satisfied Patients

A misguided attempt to improve healthcare has led some hospitals to focus on making people happy, rather than making them well.

Alexandra Robbins
The Atlantic
Originally published April 17, 2015

Here is an excerpt:

Patient-satisfaction surveys have their place. But the potential cost of the subjective scores are leading hospitals to steer focus away from patient health, messing with the highest stakes possible: people’s lives.

The vast majority of the thirty-two-question survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) addresses nursing care. For example, in a section about nurses, the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”

This question is misleading because it doesn’t specify whether the help was medically necessary. Patients have complained on the survey, which in previous incarnations included comments sections, about everything from “My roommate was dying all night and his breathing was very noisy” to “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.” An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery). “Many patients have unrealistic expectations for their care and their outcomes,” the nurse said.

The entire article is here.

Panel Urges Overhauling Health Care at End of Life

By Pam Belluck
The New York Times
Originally posted on September 17, 2014

The country’s system for handling end-of-life care is largely broken and should be overhauled at almost every level, a national panel concluded in a report released on Wednesday.

The 21-member nonpartisan committee, appointed by the Institute of Medicine, the independent research arm of the National Academy of Sciences, called for sweeping change.

“The bottom line is the health care system is poorly designed to meet the needs of patients near the end of life,” said David M. Walker, a Republican and a former United States comptroller general, who was a chairman of the panel. “The current system is geared towards doing more, more, more, and that system by definition is not necessarily consistent with what patients want, and is also more costly.”

The entire article is here.

Medicare considers funding end-of-life talks

By Pam Belluck
The New York Times
Originally published August 31, 2014

Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year.

Bypassing the political process, private insurers have begun reimbursing doctors for these “advance care planning” conversations as interest in them rises along with the number of aging Americans.

The entire article is here.

Editorial note: Politics will continue to affect health care delivery in the United States.  It is critical that healthcare providers cite foundational ethical principles when advocating for changes in our healthcare system, and not become immersed in sloganeering or bumper sticker politics to support one political party or the other.  High quality health care and informed patient choice are paramount.

Why 'Cherry-Picking' Patients Is Gaining Ground

By Leigh Page
Medscape - Psychiatry
Originally published December 19, 2013

Lower reimbursements, busier practices, and the rise of outcomes-based payments are inciting more physicians to think about cherry-picking -- that is, selecting patients with better payments or fewer health problems. Many physicians admit they do it, although they may feel guilty about it, or they worry that being too aggressive in this realm could harm their practices and standing.

Health insurers have been well known for cherry-picking members, although new regulations have eliminated some of those behaviors. But physicians do some cherry-picking, too, said Jim Bailey, MD, a professor of internal medicine at the University of Tennessee Health Science Center in Memphis, who has written about the phenomenon. If you choose a higher-paying specialty or locate your offices in an affluent suburb, cherry-picking can be a factor in keeping your practice profitable, he said.

The entire article is here.

This article comes in four parts.  You will need to click through in order to read the entire article.

CPT and ICD: What Are They? Where Do They Come From?

By Samuel Knapp, EdD, ABPP, Director of Professional Affairs
The Pennsylvania Psychologist
May 2013

The Current Procedural Terminology (or CPT) codes are developed by the American Medical Association (AMA) to ensure a common parlance and unitary language for describing services and procedures by physicians and other health care professionals. The CPT coding manual is copyrighted and published by AMA. CPT I Codes are the five-digit codes used to describe medical procedures; CPT II Codes are supplemental codes used to facilitate data collection about the quality of services provided; and CPT III Codes are for experimental procedures where data is still being gathered. HIPAA requires the standardized use of ICD and CPT codes across insurers. Although CPT codes were widely used before the HIPAA requirement, this HIPAA requirement ended the use of local codes.

A panel of the AMA (the Editorial Panel) creates the CPT codes, although it accepts advice from advisory panels. The Editorial Panel consists of 17 members including 11 physicians nominated by specialty groups within AMA; one physician each from the Blue Cross/Blue Shield Association, America’s Health Insurance Plans (a trade association), the Centers for Medicare and Medicaid Services (CMS), and the American Hospital Association; and two other members from the advisory committees to the Editorial Panel. One of the advisory committees is the Health Care Professional Advisory Committee, which consists of 12 organizations whose members are eligible to use CPT codes (audiologists, chiropractors, registered dieticians, nurses, occupational therapists, optometrists, physical therapists, physician assistants, podiatrists, psychologists, social workers, and speech therapists).

The deliberation process is secret. There is no public comment period for the adoption of these codes and no consumer input. All participants are obligated to follow strict standards of confidentiality, and the punishment for breaking confidentiality is to be removed from the process. The AMA is under no obligation to accept the recommendations of groups impacted by the changes in the CPT codes.

Although the Editorial Panel recommends the particular CPT codes, another committee within AMA, the Relative Value Scale Update Committee (RUC; rhymes with truck) recommends Medicare fees to CMS. The recommendations of RUC are based, to a large extent, on surveys conducted by impacted organizations on the relative work effort involved with the procedure. CMS typically accepts 90% to 100% of the recommendations of the RUC. Often commercial insurers set fees by paying a percentage of what Medicare pays.

Medicare payments are based on the resource-based relative value scale (RBRVS), which consists for three factors: work product, practice expense, and professional liability. Work product involves the time, technical skill, and mental effort required to perform a certain procedure. For physicians as a whole, work product consists of 48%, practice expense consists of 47%, and professional liability insurance consists of 4% of the RBRVS. For psychologists the work product is almost 70% of the RBRVS and professional liability is around 1%. Because the portion of the practice expense component for psychologists is so much lower than for physicians, minor changes in the reimbursement formula can impact psychologists quite differently from physicians.

The American Psychological Association (APA) has a representative on the Heath Care Professional Advisory Committee and had input into revising the CPT codes and the RUC process. Representatives from APA are bound by the very strict standards of confidentiality concerning their participation in the process. I have spoken briefly with APA representatives who can describe their involvement only in general terms. Participation in the process should not be interpreted to mean agreement with the recommendations concerning CPT codes or acceptance of payment.

Diseases are classified according to the ICD (International Classification of Diseases), which was developed by the World Health Organization (an affiliate of the United Nations) to gather information world-wide about the prevalence and incidence of diseases. The United States uses the ICD-cm-9, which means it is the 9th edition of the ICD. The cm refers to “clinical modification,” which is a modification of the ICD for the United States. The rest of the world uses the ICD-10, and the United States will adopt it by October 1, 2014.

Currently, the diagnostic numbers in the DSM-IV correspond to the ICD-9 codes (with a few exceptions). So psychologists can use the DSM-IV coding system and still conform to the ICD-9 system almost all of the time. However, at this time, the coding system in the DSM-V does not correspond to the numbers that would be used in the ICD-10. Although psychologists may wish to learn about the DSM-V as a way to keep abreast of new developments in the area of diagnostics, they will continue to bill only with the ICD-9 (DSM-IV-TR) numerical codes even after the DSM-V is released. Psychologists and other health care professionals will begin coding with the ICD-10 in October 2014.

SGR Repeal Bill Favors Primary Care

Robert Lowes

MedScape Medical News
Originally published February 06, 2013

Two members of Congress today reintroduced an ambitious bill that would repeal Medicare's sustainable growth rate (SGR) formula for setting physician pay and gradually phase out fee-for-service (FFS) reimbursement.

One major difference this time around for the bipartisan bill, originally introduced in May 2012, is that its price tag appears considerably lower, making passage more likely.

When Reps. Allyson Schwartz (D-PA) and Joe Heck, DO (R-NV), proposed this legislation last year, the Congressional Budget Office (CBO) had estimated that repealing the SGR and merely freezing current Medicare rates for 10 years would cost roughly $320 billion.

Since then, the CBO has reduced that 10-year estimate on the basis of lower than projected Medicare spending on physician services for the past 3 years. In a budget forecast released yesterday, the agency put the cost of a 10-year rate freeze at $138 billion.

The immediate effect of the bill from Schwartz and Dr. Heck, titled the Medicare Physician Payment Innovation Act, would be to avert a Medicare pay cut of roughly 25% on January 1, 2014, that is mandated by the SGR formula. Instead, the bill maintains 2013 rates through the end of 2014.

After 2014, Medicare would begin to shift from FFS to a methodology that rewards physicians for the quality and efficiency of patient care. From 2015 through 2018, the rates for primary care, preventive, and care coordination services would increase annually by 2.5% for physicians for whom 60% of Medicare allowables fall into these categories. Medicare rates for all other physician services would rise annually by 0.5%.

Meanwhile, the bill calls on the Centers for Medicare & Medicaid Services (CMS) to step up its efforts to test and evaluate new models of delivering and paying for healthcare (experiments with medical homes, accountable care organizations, and bundled payments are already underway). By October 2017, CMS must give physicians its best menu of new models to choose from. Two menu options would allow some physicians unable to fully revolutionize to participate in a modified FFS scheme.

The entire article is here.

Antipsychotics overprescribed in nursing homes

By M. Price

The Monitor on Psychology

September 2011, Volume 42, No. 8

Print Version: Page 11

Physicians are widely prescribing antipsychotics to people in nursing homes for off-label conditions such as dementia, and Medicare is largely picking up the bill, even though Medicare guidelines don't allow for off-label prescription reimbursements, according to an audit released in May by the U.S. Department of Health and Human Services Office of the Inspector General.

The findings underscore the fact that antipsychotics are often used when behavioral treatments would be more effective, psychologists say.

The office reviewed Medicare claims of people age 65 and older living in nursing homes in 2007—the most recent data at the time the study began—and found that 51 percent of all claims contained errors, resulting $116 million worth of antipsychotics such as Abilify, Risperdal and Zyprexa being charged to Medicare by people whose conditions didn't match the drugs' intended uses. Among the audit's findings are:

• 14 percent of the 2.1 million elderly people living in nursing homes use Medicare to pay for at least one antipsychotic prescription.
• 83 percent of all Medicare claims for antipsychotics are, based on medical reviews, prescribed for off-label conditions, specifically dementia.
• 22 percent of the claims for antipsychotics do not comply with the Centers for Medicare and Medicaid Services' guidelines outlining how drugs should be administered, including those guidelines stating that nursing home residents should not receive excessive doses and doses over excessive periods of time.

The report suggests that Medicare overseers reassess their nursing home certification processes and develop methods besides medical review to confirm that medications are prescribed for appropriate conditions.

Why such high rates of overprescription for antipsychotics? HHS Inspector General Daniel Levinson argued in the report that pharmaceutical companies' marketing tactics are often to blame for antipsychotics' overprescribing. Victor Molinari, PhD, a geropsychologist at the University of South Florida in Tampa, says that another important issue is the dearth of psychologists trained to provide behavioral interventions to people in nursing homes. While he agrees that people in nursing homes are taking too much antipsychotic medication, he believes nursing home physicians are often responding to a lack of options.

Many nursing home administrators are quite savvy in their mental health knowledge and would prefer to offer their residents the option of behavioral treatments, Molinari says, but when residents need immediate calming, physicians will turn to antipsychotic medication because it's quick and available. Additionally, he says, many nursing home staff aren't educated enough about nonmedical options, so they go straight for the antipsychotics.

"It follows the saying, 'If your only tool is a hammer, everything is a nail,'" he says. "Nursing homes are not just straitjacketing residents with medications as a matter of course, but because there are a host of barriers to giving them optimal care."